Provider Demographics
NPI:1073783734
Name:MOUNT CARMEL DENTAL, LLC
Entity Type:Organization
Organization Name:MOUNT CARMEL DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:I
Authorized Official - Last Name:QUEIJA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-796-0310
Mailing Address - Street 1:5551 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 101-A
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4651
Mailing Address - Country:US
Mailing Address - Phone:954-796-0310
Mailing Address - Fax:
Practice Address - Street 1:5551 N UNIVERSITY DR
Practice Address - Street 2:SUITE 101-A
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4651
Practice Address - Country:US
Practice Address - Phone:954-796-0310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-08
Last Update Date:2008-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12459122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty